Provider Demographics
NPI:1093864332
Name:HASTINGS, STACIA C (OTRL BCP)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:C
Last Name:HASTINGS
Suffix:
Gender:F
Credentials:OTRL BCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11940 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2007
Mailing Address - Country:US
Mailing Address - Phone:770-754-0085
Mailing Address - Fax:770-754-9288
Practice Address - Street 1:11940 ALPHARETTA HWY
Practice Address - Street 2:SUITE 150
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009
Practice Address - Country:US
Practice Address - Phone:770-754-0085
Practice Address - Fax:770-754-9288
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA706253431AMedicaid